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The Heart of the Matter: What Does America Really Know about Coronary Artery Disease Treatments? In a continuing study at the medical school in Hanover, Germany, the researchers discovered the degree to which the patient's general well-being plays a role in connection with tinnitus.
While some people examined in the study hardly noticed their tinnitus others suffered a lot from the continuous ringing or buzzing in their ears. Unfortunately you cannot use our pictures, as we do not have the copyright, but only have the right to use them on our website.
To play the media you will need to either update your browser to a recent version or update your Flash plugin. How to cite this article Mahmoudian S, Shahmiri E, Rouzbahani M, Jafari Z, Keyhani MR, Rahimi F, Mahmoudian G, et al.
Tinnitus is a debilitating condition that is widespread yet difficult to successfully diagnose and treat. Regarding to McFadden (1982), Tinnitus is the "conscious experience of a sound that originates in an involuntary manner in the head of its owner or may appear to him to be so"1. Some underlying causes were defined for tinnitus, including otological diseases, tumors, ototoxicity, acoustic trauma, noise-induced and psychological disturbances. Since almost the majority of tinnitus questionnaires for assessing individual's reaction to tinnitus are in English language and there is still no standardized and valid questionnaire in Persian, the provision of a Persian version of these questionnaires according to the culture of Iranian society is inevitable. The first aim of the current study was to investigate the linguistic validity of the Persian Version of the THI as a measure of tinnitus-related reactions in three dimensions 95 International Tinnitus Journal, Vol. The present study consists of translation and standardization of the original version of THI [25] into Persian version (Linguistic validation) then the reliability of the Persian version of THI has been identified. In the first step according to the IQOLA protocol26, THI questionnaire was translated by two native speakers of Persian, bilingual in English and Persian, separately translated the original instrument into Farsi (Persian) language (translator 1 and 2).
At the second step of linguistic validation, we used two other translators (5 and 6) with high level of proficiency in Persian and English languages. Before the THI-P can be administered to assess the effects of tinnitus, its test-retest stability must be determined.
The degree of hearing loss is defined as the severity of the hearing loss measured by audiometry.
Patients were asked to complete the THI-P questionnaire as part of the initial assessment at the tinnitus center. All analyses were performed using statistical package for social science (SPSS) version 16.
Student t-test was used to test for differences between THI scores and its subscales and gender, hearing impairments and tinnitus laterality. From the 25 items of THI-US version translated to Persian version of THI, thirteen items (52%) including 2, 3, 7, 8, 9, 10, 11, 15, 16, 20, 21 and 22 as an easy translation, six items (24%) including 6, 12, 14, 17, 18 and 19 as a relatively easy translation and finally other six items including 4, 5, 13, 23, 24 and 25 as a difficult translation were evaluated by translators. The tinnitus characteristics of the 112 subjects attending the tinnitus center to consult about tinnitus management have been summarized in Table 1. The frequency distribution of tinnitus subjects who answered the various items in the THI-P questionnaire has been outlined in Table 3. The correlation of age and total THI-P score was calculated by Pearson's product and for calculating the effect of sex and total THI-P score we applied independent student t-test.
Pearson product-moment correlations were calculated between the first and second administrations of the THI-P among the tinnitus subjects to assess the strength of the relationship between tests and retest (Figure 2). We assessed the percentages of "Yes", "Sometimes" and "No" answers and then we calculated the reproducibility (internal consistency reliability) of items in THI-P using the Cronbach's-alpha coefficient. In recent years, the need to assess and consider the consequences of diseases as well as distressing symptoms has been specifically considered in all special facilities of medical and rehabilitation. Hence, as a first step, standardization and validation of appropriate tools such as psychometric questionnaires are very important in order to evaluate disease or monitor treatment outcomes. One of our ultimate goals for validating the Persian version of THI and for conducting current study was to develop a standard self-report tinnitus instrument, appropriate to the Persian's culture so that it could be administered as a criterion measure in clinical and research approaches available to clinicians and other researchers who are involved in different aspects of tinnitus subjects.
It is widely agreed that in addition to desirable translation to validate an assessment tool, we should also use the terms adapted for socio-cultural setting of the population which will serve.
The translation quality was assessed by translator 3 and 4 using a VAS criterion (from desirable up to absolute undesirable score). In order to determine the divergent or discriminate validity of THI-P, we used the effects of three factors including hearing impairment, gender and age of the tinnitus subjects on the questionnaire scores. Regarding to other studies, in order to identify validity of THI questionnaires (German, Brazilian, Danish versions), authors administered the correlation between items in translated THI with the other standardized questionnaires (convergent validity structure)33.
The most important specifications of one assessing instrument are always including repeatability, consistency and validity of obtained scores.
The other part of consistency was related to the correlation between test-retest which was evaluated by Pearson correlation coefficient. In this study, with omitting any of the THI-P items, the acquired score of Cronbach's alpha coefficient as calculated by the total score of Cronbach's alpha coefficient was very close (r = 0.943). In conclusion, this study demonstrated that the Persian version of THI (THI-P) is a valid and reproducible tool to assess the psychological complaints of tinnitus sufferers.
We find that THI-P in structural and practical point of view is compatible with the original English version of THI. In this era, the determination of both objective and subjective effects of clinical intervention is critical, because clinicians using outcome measures could make decision about patient's status and the effective treatment. Introduction: Research on the workplace has emphasized the effects of noise exposure on workers' hearing, but has not considered the effects of agrochemicals. This study evaluated the interference of tinnitus on the quality of life for noiseexposed workers enrolled in a hearing conservation program. Most tinnitus research has focused on effective treatments and the mechanisms of the cause, detection, and perception of tinnitus. In addition to its medical and audiological aspects, the psychosocial consequences of tinnitus can be of significance and have also been investigated. Tinnitus is a common complaint among noise-exposed workers, and in some countries it is even recognized as a work-related condition for compensation purposes. The objective of our study is to evaluate the impact of tinnitus on the quality of life of workers who are exposed to noise and enrolled in a corporate hearing conservation program.
We enrolled participants from a meat-packing facility in the state of Rio Grande do Sul, Brazil. We administered a questionnaire to all the employees of the company (N = 372) at the beginning of the training sessions of their hearing conservation program.
To assess the workers' hearing status, we performed otoscopy and pure-tone audiometry, according to the requirements of the Brazilian legislation [10]. We administered to the 52 participants the Brazilian version of the Tinnitus Handicap Inventory (THI) questionnaire, elaborated by Newman et al.
We calculated Pearson coefficients of linear correlation and tested their significances via the Student's t -test and Fisher's exact test, using a significance level of 5%. Eighty-two workers (22%) of the total population of 372 workers in the studied company reported tinnitus in the first interview of this study. Company records also indicated that 15% of the participants who were exposed to noise were also exposed to other hazards. The results of the relationship between tinnitus and the three THI scales are presented in Figure 2. Table 2 displays the correlations between the functional, emotional, and catastrophic scales and medical history.
Table 3 presents the correlations of the THI results with the health problems described by the participants (n = 52). We separated the participants into two groups: The first was composed of 37 participants with normal hearing (71%), and the second included 6 participants (12%) with a bilateral high-frequency notch. Twenty-two percent of the noise-exposed participants complained of tinnitus, a finding comparable to rates of 25% reported by Sahley and Nodar [14] and 15.5% reported by Zimmermann [15].
Seventy-one percent of the participants with tinnitus complaints presented normal audiometric results, which suggests that tinnitus can be an early indicator of auditory risk from exposure to noise. The application of the Brazilian version of the THI was both easy and expedient, as indicated by Newman et al. In Table 2, we found significant results involving the functional scale results with the use of prescription drugs and the catastrophic scale results with consumption of coffee. Concerning the degree of severity of tinnitus, 44% presented degree 1 or "slight" tinnitus according to the classification by McCombe et al. We observed a significant correlation between tinnitus severity and exposure to noise and chemical pollutants, predominantly CO. We observed a significant correlation between the duration of noise exposure and the emotional scale for the participants with high-frequency notches, suggesting an extra-auditory effect of noise. The results of this study demonstrated that the prevalence of tinnitus was high (22%) in this population, despite the fact that study participants were young individuals who had a short duration of noise exposure.
The Brazilian version of the THI proved to be an easy instrument to use for evaluating the impact of tinnitus on the quality of life of noise-exposed workers.
The latter often end up in a vicious circle of sleep disorders, and some even suffer from depression. The only condition is that you provide a direct link to the specific article you use on the page where you quote us. Persian language version of the "Tinnitus Handicap Inventory": translation, standardization, validity and reliability.
This symptom is a debilitating condition that is widespread yet difficult to successfully diagnose and treat. For some patients with tinnitus this sensation does not interfere with their daily activities and for others it is disabling and restricts their work, sleep, and social activities10,11. Numerous studies using various open-ended or self-report structured questionnaires have been conducted. For this reason we perform according to the International Quality of Life Assessment protocol (IQOLA) approved by WHO in 1991. Craig Newman, author of the original questionnaire of THI, has permitted us to develop and use the Tinnitus Handicap Inventory in Persian Language Version. They were asked, if needed, to mention a list of possible translations for some words, sentences and phrases.
On the other hand, the words and items on the level of reading ability of 14 years old or less were noticed for linguistic validation of THI-P. All subjects gave written informed consent in accord with the declaration of Helsinki before examinations. So, in retest after one week from filling the first THI-P, the questionnaire was filled again by the same patients. Descriptive statistics, including frequency distributions, means and standard deviation were computed for each item of THI-P. Multiple linear regression analysis was used to study the effect of gender, hearing loss and the tinnitus laterality on the overall THI score as well as the functional, emotional and catastrophic subscales. In this study, the research method and the role of subjects were explained clearly and completely.
The translation clarity exception in one item (item 17) which was evaluated as relatively desirable, in the other 24 items (96%) of THI-P was evaluated as desirable. Most of tinnitus subjects (72.7%) perceived one type of tinnitus sound, while others complained of sensation of more than one type of sound on different occasions. Scatter plots illustration the relationship between the THI-P score and the age in all subscales. As shown in Figure 2, the scatter plot indicates the correlation between the first (test) and second (retest) administration of the THI-P and their subscales on tinnitus subjects.
Scatter plots illustration the correlation between the first (test) and second (retest) administration of the THI-P and their subscales. Researches in many different countries around the world in this area indicate the global emphasis on the importance of these assessments. This symptom is as a common problem which can affect several aspects of patients' life including: going to sleep, understanding speech, depression, irritation, concentration and worse on awakening. To acquire this expressed goal, it was necessary to translate and standardize the original version of THI and then to evaluate the test-retest reliability of the THI-P. The measure of difficulty of Persian translation of THI was evaluated by translator 1 and 2 using a visual analogue scale from easy up to difficult (VAS; 100 mm total length). The measure of this criterion administers three measures including clarity scores, common language and identifies conceptual equivalence. Both convergent and discriminate validity methods were used for identifying validity of original English version of THI19. In current research the reliability of THI-P was evaluated from two 102 International Tinnitus Journal, Vol.
We obtained 0.96 in Persian THI version, consistent with significant correlation in retest. The findings showed that none of the items of the Persian version of the questionnaire need to be removed.
Also, THI-P could be administered as a standard measuring instrument for patients and clinicians all over Iran. Henceforth, THI-P could be used for both clinical and research purposes by different professionals like audiologists, otolaryngologists, psychiatrists and could be also used for monitoring, treatment and rehabilitative effects on the life's quality of tinnitus sufferers.
ENT and Head & Neck Research Center, Hazrat Rasoul Akram Hospital, Tehran University of Medical Sciences (TUMS), Tehran, Iran. Department of Audiology, School of Rehabilitation Sciences, Tehran University of Medical Sciences (TUMS). Department of Biometry, School of Rehabilitation Sciences, Tehran University of Medical Sciences (TUMS).

Aim: To evaluate and correlate the hearing level and tinnitus of workers exposed simultaneously to noise and organophosphates in their workplace and to measure tinnitus distress on their quality of life. Noise measurements, a questionnaire, a Brazilian version of the Tinnitus Handicap Inventory (THI), and pure-tone audiometry were conducted with 52 participants (mean age, 29 years) who suffered from tinnitus. Among the risk factors for tinnitus, the most prominent are age, gender, various diseases (otological, metabolic, neurological, and vascular alterations and dental factors), hearing loss, and exposure to noise, ototoxic drugs, caffeine, nicotine, and alcohol [1-4]. Tinnitus can alter an individual's ability to function in professional, social, and leisure activities and in family relationships, hence affecting the quality of life [5,6].
In addition to being beneficial for clinical applications, the tinnitus questionnaires are valuable for understanding the relationship between personality and the psychopathology of tinnitus, its impact on the daily life of persons who suffer from tinnitus, the difficulties and the perception of social support in relation to the problem, and the incapacities and the difficulties produced by tinnitus that can seriously affect quality of life [7-9]. Occupational hearing loss prevention initiatives rarely focus on the prevention and management of tinnitus.
The company employs 372 workers (120 female, 252 male) working in two fixed 8-hour and 48-minute shifts. The questionnaire gathered information on demographics and occupational and medical histories for each worker. We also used Spearman's rank correlations to examine the results of exposure information versus the outcome.
Because of attrition, we were able to study only 52 workers (14% of total population of the plant). Of those, 62% were exposed to carbon monoxide (CO), 13% to CO and vibration, 12% to hydrochloric acid, and 13% to sodium hydroxide.
We observed that of the 52 participants, 71% had normal audiometric results, whereas 12% presented a bilateral high-frequency notch and 17% presented audiometric configurations of hearing loss due to causes other than noise, such as unilateral losses and flat audiometric configuration.
Median of hearing thresholds for the groups with normal hearing (all thresholds 25 dB hearing level [HL]), hearing loss configurations suggestive of noise-induced hearing loss (NIHL), and hearing loss from various causes. The distribution of poorest scores across scales of the Tinnitus Handicap Inventory, in percent (n = 52). We observed a significant correlation between headaches (p = .0458) and the duration of tinnitus. We did not include the remaining 9 individuals (17%), who displayed other audiometric configurations of hearing loss in the statistical analysis. The prevalence of tinnitus complaints in male subjects was 16% and in female subjects was 9%, similar to what has been reported [16-18]. Schleuning [2] explained that caffeine and nicotine could aggravate tinnitus because they are stimulants and can induce the constriction of blood vessels. The participants of the study who had such combined exposure had a higher degree of tinnitus severity. Moreover, a negative impact of tinnitus on the subjects' quality of life could de detected. The 22% tinnitus rate among workers, most of whom nonetheless had normal hearing, suggests a need to address tinnitus in occupational hearing loss prevention initiatives. Rick Davis and Robert Randolph (National Institute for Occupational Safety and Health, USA) and Alberto Behar (University of Toronto, Canada) provided helpful critiques of the manuscript.
People of calmer disposition and a general sense of well-being suffer far fewer psychological effects from the continuous buzzing or ringing in the ears.
Objectives: The aim of current study was to compose and validate a Persian version of the Tinnitus Handicap Inventory (THI-P). The prevalence of chronic tinnitus in the general population is estimated between 5-15% and causes to develop serious psychosocial complications in 1% to 3%1.
It is reported that tinnitus can be severe enough to cause significant discomfort in one's daily life12.
Finding the effects of tinnitus on the quality of life and assessing the individual's reaction to tinnitus are very important. The aim of IQOLA is to translate and provide health questionnaires with high validity and reliability for using in different countries by their formal language26.
This version is both simple to administer and interpret and also a powerful psychometric tool.
After that, each of the expert translators were asked about the difficulties of the translations and they were attributed a score according to the 100 point visual analogue scale (VAS). Afterward, the pooled back translation was compared and formed by translators and then an agreement was obtained for one English version of THI questionnaire for finding the coherency with original version.
Therefore the formulated initial Persian version of the instrument was attended by 24 (10 female and 14 male) high school students in Tehran.
The Cronbach's Coefficient Alpha test (where values>0.70 indicate a satisfactory internal consistency) was used to test for the evaluating internal stability of the THI-P29, and Pearson correlation coefficient was calculated between the total score of the THI-P and the scores of its subscales, age and pure tone average (PTA).
The common language score of THI-P was assessed as desirable in all 25 items (100%) and also the conceptual equivalence for three items (4, 10, 16) undesirable response (12%), for two items (23 and 14) in a relatively desirable level (8%), and the other items were desirable response (80%). The type of sound reported by most tinnitus subjects was subjectively described as high-pitch tone, matched by external stimuli (described by 52.3% of subjects). Table 2 summarized the mean air conduction thresholds across frequencies of 500-4000 Hz for left and right ears. As shown in Figure 1, the total score of THI-P and its subscales were not correlated with the age of tinnitus subjects.
Total score of the THI-P and its associated subscales are very close to corresponding values in the original THI-US (Table 6). In Iran, in order to converge and coordinate with the ongoing research at the international level concerning the evaluation of consequences of diseases, impairments, handicaps, treatments and rehabilitation, we should create a new movement. Sense of the various problems among the subject sufferer from tinnitus and understanding the impact of tinnitus on their quality of life are of the uttermost importance. Translation of the original questionnaire of THI in Persian language in overall was easy due to its simple sentences, whereas, the translators in six items acknowledged difficult translation (items of 4, 5, 13, 23, 24 and 25).
The translation clarity in 24 items of THI-P was evaluated desirable and only one item (item 17) evaluated as relatively desirable. Majority of epidemiological tinnitus studies have reported a positive relationship between tinnitus and hearing loss4,34-35.
This valid tool allows us to quantify how much tinnitus impacts the life's quality of these individuals. Functional brain abnormalities localized in 55 chronic tinnitus patients: fusion of SPECT coincidence imaging and MRI. Prevalence of tinnitus and hearing thresholds of a non-noise-exposed population with and without tinnitus. Assessment of psychopathological aspects and psychiatric comorbidities in patients affected by tinnitus. Psychologic profile of tinnitus patients using the SCL-90-R and tinnitus handicap inventory.
Psychological profile and somatic complaints between help-seeking and non-help-seeking tinnitus subjects. Tinnitus reaction questionnaire: psychometric properties of a measure of distress associated with tinnitus. Developmental and Psychometric Adequacy of the Screening Version of the Tinnitus Handicap Inventory. Psychometric Adequacy of the Tinnitus Handicap Inventory (THI) for Evaluating Treatment Outcome. Tinnitus with normal hearing sensitivity: extended high-frequency audiometry and auditory nerve brain-stem-evoked responses.
Validity of the Italian adaptation of the Tinnitus Handicap Inventory; focus on quality of life and psychological distress in tinnitus-sufferers. Brazilian Portuguese Language version of the "Tinnitus Handicap Inventory": Validity and Reproducibility. Impact of tinnitus as measured by the Tinnitus Handicap Inventory among tinnitus sufferers in Singapore. Therefore, further research is necessary to improve understanding of the combined effects of noise and chemicals on hearing.
THI results indicated that tinnitus had the greatest influence in the functional scale (54%). We used the overall result to identify the degree of severity of tinnitus for each individual and for completing an analysis of the total scores by scales. Of all noise-exposed female workers in the plant, 11 (9%) reported having experienced tinnitus, and 41 (16%) of the noise-exposed male workers reported the condition. Spearman's rank correlation coefficient results indicated a significant correlation between noise levels and how often workers experience tinnitus (p = .01).
We also observed a significant correlation between the duration of noise and the functional scale (p = .039). It is important to notice that the average age of the population of our study (29.2 years) is younger than in other studies, which reported results from groups whose mean ages varied from 40 to 50 years and who had a short duration of noise exposure (average, 7 years)[18-21] .
According to that author, doctors believe that 50% of patients with complaints of tinnitus improve significantly when they stop smoking or reduce caffeine intake. In recent decades, studies have demonstrated that simultaneous chronic exposure to CO and noise represents a potential risk to hearing, but reports of tinnitus exist only for cases of intense poisoning from CO [24].
This supports the inclusion of tinnitus prevention initiatives alongside workplace hearing loss prevention initiatives because of shared causal factors.
Information on tinnitus prevention and treatment could have a measurable, positive impact on a person's quality of life. The authors thank all those who participated in the study for their time, interest, and cooperation. Guidelines for the grading of tinnitus severity: The results of a working group commissioned by the British Association of Otolaryngologists.
Materials and Methods: The linguistic validation of the original version of THI into Persian version (THI-P) included translation, back translation and data gathering.
Epidemiological studies indicated that in developed countries such as Germany about 1.5 million people, in the United States about 10 million out of 40 million tinnitus sufferers and a similar ratio in the United Kingdom have been reported that were seriously affected by tinnitus2-4. Tinnitus symptoms have been linked to various psychological and psychosomatic disorders13-15.
One of the most important methods in the assessment of the severity of tinnitus and its effects on the lifestyle of a patient is the use of psychometrical evaluations.
Finally, we formulated the initial Persian version of the instrument with proper and satisfactory translation. The final version of THI-P was administered in all tinnitus subjects who were managed in our center between September 2009 and May 2010.
The score of "Yes", "No" and "Occasionally" were 4, 0 and 2, respectively in three subscales: emotional, functional and catastrophic.
All personal information in the questionnaire were confidential and only used in this research. The other descriptions of tinnitus included cricket, sizzling, hissing, humming and other sounds. Tinnitus is a subjective idiopathic symptom in which it is not detected by blood examination and CT scan or like this.
In this regard, translator 1 and 2 were asked to provide a list of possible alternative translations for the replacement in relatively difficult and difficult items of THI-P. The prevalence of tinnitus among normal hearing subjects has been reported between 7%-10%36-37.
We evaluated 82 organophosphate sprinklers from the Sao Paulo State Regional Superintendence who were active in the fight against dengue and who were exposed to noise and organophosphates. Eighty-two individuals (22% of the total population) had experienced tinnitus and were invited to participate in the study. The equipment used was an Interacoustics audiometer, model AD 229, with TDH-39 earphones, calibrated according to ISO 8253. The average age of the sample was 29.2 years, and the average duration of noise exposure was 7 years. Moreover, significant results were found for the degree of tinnitus and exposure to chemical pollutants (p = .02). The THI indicated that even the degree 1 "slight" tinnitus experienced by most of the participants who reported tinnitus nevertheless had an impact on their quality of life.
For instance, lesions in the neck and the middle ear and sinusitis and headaches increase the risk of tinnitus from 28% to 35%. The findings underscore the need for noise control and other effective strategies to mitigate causal factors. The use of an instrument designed to evaluate the impact of tinnitus on a person's life, such as the THI, can contribute to a greater understanding of the needs of a specific person or group (or both). Experiencia do hospital das clinicas da faculdade de medicina da Universidade de Sao Paulo. It is shown that 48% to 60% of patients with chronic or disabling tinnitus have major depressive disorder (MDD)16. Such self-report questionnaires include the Tinnitus Questionnaire (TQ)18, Tinnitus Handicap Inventory (THI)19, Tinnitus Severity Scale (TSS)20, Tinnitus Handicap Questionnaire (THQ)21, Subjective Tinnitus Severity Scale22 and Tinnitus Reaction Questionnaire (TRQ)23.
The THI is a 25-item self-report instrument which is divided into three subscales including functional, emotional and catastrophic reactions to tinnitus. On the basis of these two translations and their VAS scores to each THI items, we formed the pooled version that was then reviewed by presence of translators for considering suggested replacing words and difficulty in translation. This questionnaire was used as an initial instrument for gathering data from tinnitus subjects at next steps. Each single item was read loudly and the participants were asked to follow the items on the given sheet. Age, gender, medical history and tinnitus characteristics were recorded as baseline information.

In total, more than 92% of tinnitus subjects who attended the current study revealed high pitch tinnitus, matched by external stimuli (>3000 Hz). Independent Student t-tests did not demonstrate statistically difference between total THI-P score and those with or without hearing impairment, neither did those with unilateral or bilateral tinnitus (Table 4). The main problem with tinnitus is its subjective nature so that evaluation of this complaint always depends upon patient's words. These alternative items were reviewed again by translator 3 and 4 in order to optimize quality of translation and finally revised for appropriate items. In conceptual equivalence of the translation, three items had undesirable response (4, 10 and 16) and two items had relatively desirable response.
We performed pure tone audiometry and applied the translated THI (Tinnitus Handicap Inventory) questionnaire.
Twenty (24%) of the 82 were not able to participate because they lost their jobs before collection of data, 5 (6%) declined to participate saying that they no longer had symptoms of tinnitus, and 5 (6%) were on vacation at the time of data collection. We performed puretone audiometry for all subjects at frequencies of 0.5, 1, 2, 3, 4, 6, and 8 kHz.
The functional subscale, composed of 11 questions, evaluates the limitations that tinnitus induces in the mental, social, occupational, and physical areas.
Table 1 displays the findings pertaining to the health problems and auditory and medical histories described by the participants. In the THI, tinnitus was shown to have the greatest relationship to the functional scale (54%), indicating that its impact is more noticeable in social, daily, and reading activities involving concentration, auditory acuity, attention, and rest. The analysis of the THI results along with the audiometric results indicated that a considerably greater number of significant correlations were verified in the group with altered hearing, which was expected because the two conditions-compromised hearing and tinnitus-are often associated.
Information dissemination on the risks and prevention alternatives is of great importance, as is the management of tinnitus. Finally, it could be used in the design of appropriate strategies to manage tinnitus in the workplace.
In addition, tinnitus is a common symptom of the auditory system disorders that is usually associated with sensoryneural hearing loss6,7. Asplund reported that among subjects with tinnitus poor sleep and frequent waking were more common in men and women17. In this regard the client was questioned in order to find out which activity or performance of the patient is affected by tinnitus. Analysis of the THI items suggested that this self-report instrument had excellent internal consistency reliability and adequate convergent and constructive validity28.
It is worth to mention that in this step, for differentiation of the level of difficulty in translation, average scores less than 25 were considered as easy, more than 30 as difficult and between 25 and 30 as relatively easy.
Thus, items with undesirable translation were revised by translator 5 and 6 and revised by suggested replacing proper words, sentences and phrases. As reported in several studies for the original version (US), Italian, Turkish, Danish, Portuguese and Singapore translations of THI19,28,38-41, the Persian version of THI was not significantly different in the handicap scores between those with normal hearing and those with hearing impairment with regard to the degree of handicap severity. Eventually it became clear that internal consistency was high and the response of every item to the response of total items was matched. It was verified that the level of hearing loss and extent of the frequency range effect were greater in the combined exposure group (8).A high prevalence of auditory and vestibular complaints were observed in a study performed with 50 rural workers exposed to organophosphates, suggesting that these substances can affect these systems due to their ototoxic and neurotoxic actions.
Therefore, the final sample of the study consisted of 52 participants: 11 females (9% of the total of 120 noiseexposed female workers in the studied plant) and 41 males (16% of the total of 252 noise-exposed male workers in the studied plant). The emotional subscale, composed of 9 questions, includes affective answers for tinnitus (anger, frustration, irritability, and depression). All participants exposed to noise levels greater than 85 dB are required to use ear muffs, and information on their use and maintenance are given when workers are hired.
The emotional scale was the second most affected and is related to manifestations of nervousness, frustration, irritation, depression, anxiety, insecurity, and difficulty in relationships with family and friends. Estabelece diretrizes e parametros minimos para avaliacao e acompanhamento da audicao dos trabalhadores expostos a niveis de pressao sonora elevados. All participants complained of chronic unilateral or bilateral subjective idiopathic tinnitus lasting for at least 6 months before consulting about their tinnitus.
An epidemiological study in Italy based on a tinnitus questionnaire demonstrated that the prevalence of tinnitus was 8% in normal hearing subjects while this amount rose up to 30.5% in the presence of auditory dysfunctions8.
This agreed version of Persian THI translation was given to the two other translators who were expert to Persian philology (translator 3 and 4). Finally, the results of the present investigation suggest that the THI-P was simple and clear, without losing its equivalence towards cultural issues. All values of item-total correlation coefficient are greater than 0.3 which also indicated high internal consistency in THI-P except item 19. The average hearing threshold for the 4-8-kHz frequency range of the workers with current tinnitus was higher than that of the others, and was most affected at the 4-kHz frequency. We also performed daily biological calibration checks on the audiometer immediately before testing subjects. Last, the catastrophic subscale is composed of 5 questions and examines the most severe reactions from tinnitus (desperation, loss of control, inability to face problems, inability to escape tinnitus, and fear of having a serious ailment)[12].
Walkthrough observations suggest that use of the hearing protection is high, but no information exists on the consistency of hearing protection use. The catastrophic scale demonstrated alterations related to desperation, intolerance to tinnitus, and loss of control in situations when experiencing tinnitus (see Fig. Results: There was no significant difference between gender, age, hearing impairment and total score and subscales of THI-P.
Therefore, the valid psychometrical evaluations such as THI can be administered as a robust instrument to objectify tinnitus distress, but additional measures might be needed in order to catch the dimensions of tinnitus-related problems. Inoverall the translation quality of THI-P was evaluated as desirable from both aspects of a careful translation and adapted to the socio-cultural setting. This first symptom is a warning of excessive exposure to sound stimulation and may indicate increased susceptibility to damage caused by noise, and is a major symptom in preventing noise-induced hearing loss and one of the main predictive factors of handicap in workers exposed to noise (12). In our study, factors such as gender, age, tobacco, and exposure to firearms were not significantly associated with tinnitus. Pearson product-moment correlations revealed adequate test-retest reliability for the THI-P (r = 0.96).
Also the valid questionnaires are valuable in the evaluation of results from before to after special treatment and its effect on the individual's quality of life.
Coles [26], among several authors, reported that the worse the hearing is, the more probable is the occurrence of tinnitus. Therefore, the symptom of tinnitus has forced clinicians to attempt to establish protocols for accuracy of tinnitus diagnosis and treatment9.
The Tinnitus Handicap Inventory (THI)25 has gained widespread acceptance as a self-report measure of tinnitus around the world. Therefore, these translators (3 and 4) for each question determined 3 scores on the basis of 100 point criteria. Therefore, the Persian translation of THI was not affected by hearing impairment, gender and age factors.
Conclusion: There is an increased incidence of abnormal pure tone audiometry in workers with tinnitus, and its impact on the workers' quality of life was discrete. These questionnaires, assessing functional effects, are composed of several items that measure the impact of tinnitus on various aspects of daily life (16). In this VAS, zero point means absolutely improper quality and 100 means absolutely proper and satisfactory quality. After that, the subsequent processing was attended by audiologists from department and research center of otolaryngology of Tehran University of Medical Sciences (TUMS). According to some authors, their use ensures greater reliability in the evaluation of tinnitus in comparison with other methods (17).One of these questionnaires is the Tinnitus Handicap Inventory (THI) proposed by Newman et al. Approximately 20% of the patients with hearing loss present complaints of tinnitus, whereas 90% of those with severe tinnitus had hearing loss.
Criteria for decision making in improper quality of each translation items was the average score less than 90 (determined by translators 3 and 4). Accordingly, in this step, Persian version of the THI was obtained, which regarding to all translators 1 to 4, had satisfactory quality. The selection of the THI (19) was due to its confidence, ratified by high internal consistencies (13, 20).
All participants signed a consent form agreeing to participate.Ten years ago, the center developed a partnership with the Superintendence of Endemic Disease Control (SUCEN), the local authority linked to the Sao Paulo State Health Secretary, with the purpose of performing annual audiological evaluations in organophosphate sprinklers in this region. As their main task, these workers carry out vector control using chemical products, namely organophosphates (1). To perform their activities to combat endemic vectors, dengue, and yellow fever, they use Malathion®, an organophosphate that is known to be toxic to humans and carcinogenic to animals (8).
The study was performed with SUCEN workers active in the fight against dengue who were exposed to noise and organophosphates. Exclusion criteria were alterations to otoscopic inspection that prevented procedures from being performed, presence of conductive or mixed hearing loss (21), type B tympanograms (23), and one of the procedures not being performed.First, we performed an audiological clinical history. The final score classifies the tinnitus handicap as discrete (0-16 points), mild (18-36), moderate (38-56), severe (58-76), and catastrophic (78-100).Then, we carried out basic audiological evaluation composed of pure tone audiometry and tympanometry.
The pure tone audiometry was performed in a sound-isolated booth using a GSI-61 audiometer (Grason-Stadler) with TDH-50 supra-aural earphones. When the threshold found was 25 dB or greater, we performed bone conduction testing in the 0.5-4-kHz frequency range. Given the preventive nature of this technical standard, subjects whose audiogram revealed a hearing threshold of 25 dB (HL) or less at all frequencies evaluated are considered to be within normal limits.
After sealing the ear canal, we carried out the tympanometry, a dynamic measurement of the acoustic impedance that verifies the level of mobility of the tympanic-ossicular system. A value of -1 represents a perfect negative correlation and +1 represents a perfect positive correlation. The value of 0 represents no correlation.RESULTSTo analyze the results, the sample was divided into 2 groups according to the presence or absence of tinnitus. In individuals with low-medium- or high-frequency hearing loss, noise exposure has been associated with a greater chance of developing persistent tinnitus (25).A cross-sectional prevalence study, conducted with 98 agrochemical sprinklers who worked in campaigns to prevent dengue, yellow fever, and Chagas disease, aimed to estimate the incidence of hearing loss in this population. A previous study in a similar population reported the presence of hearing loss at frequencies between 3 and 8 kHz (6, 26). Perhaps this practically identical configuration can justify why this important issue has been neglected for many years.
The greatest damage usually occurs at 4 kHz, and the higher and lower frequencies are affected more slowly than that within the 3 and 6 kHz range (4).In a study with workers exposed to several types of agrochemicals, including organophosphates, 2 groups of 42 men were formed (a group composed of agriculture workers with at least 15 years' experience and another composed of workers without agrochemical exposure and without hearing loss history).
The results showed that 60% of the workers exposed to agrochemicals had a lowered hearing threshold, and that 23 of them had bilateral sensorineural hearing loss.
However, there has been no systematic evaluation of the link between perceived tinnitus distress and underlying hearing loss.
The underlying hearing loss can be a significant factor in the perception of the distress (29).Patient distress is a very subjective symptom and frequently depends on external and psychological factors beyond the negative assigned to that of tinnitus (28). The author justified these findings with the fact that the data were not selected from a specialized medical service, nor had the subjects received any kind of tinnitus treatment. The authors reported that both hearing loss and tinnitus were "impairments" resulting from loss or abnormalities of function of the cochlea, vestibulocochlear nerve, or the central auditory pathways. Both these symptoms tended to restrict normal activity (29).Individuals with tinnitus may suffer several degrees of distress, and this may have a higher or lower impact on the quality of life. Two important factors are related to tinnitus and should be differentiated: the intensity of the tinnitus signal and the severity of the symptom (the distress it causes to the patient's life). The correlation between the average hearing threshold and tinnitus distress was weak, and there was a tendency for threshold values to increase along with THI scores.REFERENCES1. Gerenciamento participativo em saude do trabalhador: uma experiencia na atividade de controle de vetores.
Suggested guidelines for studying the combined effect of occupational exposure to noise and chemicals on hearing.
Exposicao ocupacional ao ruido e quimicos industriais e seus efeitos no sistema auditivo: revisao de literatura. NoiseChem: An European Commission research project on the effects of exposure to noise and industrial chemicals on hearing and balance.
Interacao entre grau de perda auditiva e o incomodo com zumbidos em trabalhadores com historia de exposicao ao ruido.
Hearing loss from industrial noise, head injury and ear disease - a multivariate analysis on audiometric examinations of workers.
Guidelines for the grading of tinnitus severity: the results of a working group commissioned by the British Association of Otolaryngologists, Head and Neck Surgeons. Estabelece parametros e diretrizes minimos para a avaliacao e acompanhamento da audicao de trabalhadores, expostos a niveis de pressao sonora elevados.
Impact of tinnitus as measured by the tinnitus inventory among tinnitus sufferers in Singapure.
Avaliacao audiologica e de emissao otoacustica em individuos expostos a ruidos e praguicidas. Could an underlying hearing loss be a significant factor in the handicap caused by tinnitus?.
Newman, CW, Sandridge SA; Bolek L+ Development and Psychometric Adequacy of the Screening Version of the Tinnitus Handicap Inventory. Psychopathological profile of tinnitus sufferers: evidence concerning the relationship between tinnitus features and impact on life.

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